The almost-doctor returns to Cameroun

Dear all,

I'm writing from Yaoundé, Cameroun. I will be updating my blog again during the next month, as I am working with Ascovime (www.ascovime.fr), an NGO here that does health campaigns in rural villages, among other things, incorporating clinical work and public health. 

I will do some writing in French, but Spanish...lo siento. 

I'm less than two months from my medical school graduation. 

Everything comes full circle. I took the MCAT weeks prior to leaving for Cameroon, the first time. I got my MCAT scores while in Bandjoun for training--my parents called. My fellow (then) Peace Corps Trainees knew I had been waiting to hear, and they were ecstatic for me--if I had to take the MCAT again, it would have been 3 years later, delaying medical school more (at the age of 22, I thought that time like that mattered). I saw my first surgery in Cameroon, a week and a half after arriving at post--December 30th, I think, 2005. I set foot in the OR in Mvangan in chacos and capri pants, probably with sunglasses pushing back my hair. My job was to hold down the patient's legs, so he'd stop kicking Doc who was trying to repair the perforated bowel piled in loops on top of his abdomen. I counseled my first patients, there--HIV, malnutrition. Learned and taught health professionals about preventative and public health. I ran a health district.

And then I applied to med school. Middle of my second year of Peace Corps service, June 2007, AMCAS--I turned it in the first day it opened; I'd had time at post to prepare the essays with help from my Peace Corps Volunteer friends. Everything was ready ahead of time because it had to be. I couldn't guarantee when I'd be in the city, and even if I was, when power would be working, when internet would be working...etc. Before that, I remember taking the (few years old) book of medical schools from the Case, our Volunteer house in Yaounde, and poring over it on the woven plastic mat in my house in Mvangan, by candlelight. I crosslisted schools by research rank, primary care rank, and school of public health (and then it turned out that the best one for me doesn't actually have a school of public health (well, at Berkeley, across the Bay), and I went for MFA and not MPH). I knew no one else applying, that year, I knew little more about the schools and process than what was in the years-old book, and everyone around me was supportive and helpful. A friend brought me my old laptop from the US, and when Doc's generator was on in Mvangan (and he always generously connected it to my house), I'd type furiously for my secondary essays, writing and editing otherwise by hand, and emailing/updating every 2-3 weeks in Ebolowa (almost missed an interview invite. Didn't). I scheduled all the interviews while I was in Cameroon, and I started interviewing a week after I returned to the US.

Medical school is why I left Cameroon. I very seriously considered extending my service for a third year and delaying med school, or staying for 6 months, or somehow going back to the States to interview on home leave and tell them I was planning to start in 2008--and then defer until 2009 after I got in. But my MCAT scores were expiring, for some schools (including UCSF), and so I left. In the end, I decided because I wanted Mvangan to have (two!! health and agro) volunteers for two more years, it was better to leave; I wouldn't have added enough time.

And for the first two years of med school, at least, I considered dropping out - frequently. Several per month. In order to go back to Peace Corps, do Peace Corps Response (then Crisis Corps), be a UN Volunteer...I was on email lists for all kinds of positions, and any time not being there felt like too long away. After being in the US for about 6 months (when I finished my service, interviewing for medical school, etc), I had the opportunity to go back to Africa, Kenya this time, for public health research (funded) - and I ran. I was away from Africa for 6 months. Then, 10 months. And now...three and a half, almost four, years. A friend said to me once, "it's hard to imagine there was a time when you'd never been to Africa." True.

I was called "dokita" for the first time in Cameroon; http://jenny-and-cameroon.blogspot.com/2006/05/paging-dr-jenny.html. I was introduced as "Docteur Stella, une etudiante..." by Dr. Ndom when I went back the summer between my first and second years of medical school. And now? It won't feel disingenuous. I'm returning to the States from Cameroon in order to graduate. I've finished all my credits. Really, I'm done.

In Cameroon, in Mvangan, I found the kind of medicine and public health that I want to practice. I had to leave in order to learn. My "back up plan," I told people, if I didn't get into medical school, was to stay, learn with Doc, and buy a medical degree (quite possible in Cameroon). Now? I'll be signing my residency contract in Cameroon and sending it from the Peace Corps office in Yaounde. 

When I was there, Bush and Cheney were on the walls in the office (in federal offices, required). We shuddered every time we walked in. Now? Much has changed.

My name is still on the wall, I'm told --- literally. My group decided that we would sign the wall in the Case when we COSed. Since then, some others have, but not all. My name, my writing, is still on the wall, just like it is in homeless clinic here.

---

As I was flying in last night.

The capital city is barely lit. At 2 miles up, it's 51°F. 66°F, a mile and a half.

You wouldn't know this was the second biggest city (I don't remember if Douala was more lit, arriving at night). Quiet. The only thing about this country that is. The rainforest, every night, was loud and exultant. Insects make noise, animals, people. Silence usually implied ear plugs. 

The way to the airport is dark. Pitch, in this almost-on-the-equator country with 12 hours of each day and night. 73°F at 3000 feet. The plane feels it, already. It was dark as we edged over the Sahara. Sahel. I know where we are and what it looks like. This, too, is rainforest. 

We land. The entire plane erupts in applause.

Outside, I will kiss my fingertips and press them to the ground. It's a mark of reverence, of respect. In African dance, we do this in front of each drummer, at the end. Here, I do it when I leave.

And every time I return.

On est ensemble - we are together - estamos juntos - bi ne vale!

~j

A Hell of a Town

I wrote most of this ~ 3 weeks prior to leaving New York. "Here," then, refers to NYC.

There are two ways to parse that.

Before moving here, I thought HELLUVA town. Hells yeah.

Moving here? a HELL of a town.

Now – it’s both. Everything is both. Everything is ambivalence.

I bike to work – felt like a legit NYC commuter today, messenger bag and all. Door-to-door, to bustling Long Island City and the DOHMH* with the secure bike room. Used my ID three times to get into the most secure building I've ever entered, belonging there. I rode under the BQE, across the Pulaski Bridge, right into Queensborough plaza.

*Department of Health and Mental Hygiene

That felt like the boldest part, first time. I used to commute to school, from my old apartment/old schedule. But that’s all in Brooklyn. Now, crossing the bridge. Crossing boroughs. And as I cross the bridge, to my left, across the East River, is midtown Manhattan. One of these days I’ll pull over to take a picture. It’s a narrow, two-way path, up up and over, with pedestrians and bikers--all commuters, at that hour. So I watch, crane a little. It’s beautiful. I don’t go to work before sunrise, anymore, and I go home before sunset. At this time of year.

Dawn at the DOHMH, before going to Riker's Island jail to do Hep C education

...before beauty

So many more patients on our service are my age than I'd like to count. They're all older – by 6 months, 3 months. There's an age I don't have to think about, looking at the year*. I know.

It's an adult service, and I'm going into adult medicine. But none of them, right now, are younger than me. No one should be and be this sick.

*yes, other times I get the subtraction wrong…

It’s HIV, AIDS, whatever CDC or WHO classification you’re using these days. Every patient I have, right now. Without exception.

When I was at the VA, first for emergency psych, and then later for surgery, it used to surprise me how all of my patients had been “in the service.” (strange thing to forget, when working in a hospital for veterans). Mostly in Vietnam, as the stereotype goes. History of mental illness, mostly, substance use, and then everything else that happens to so many sixty-odd-years old men. If you have private insurance, you don’t go the VA. There’s your demographic.

I’m not used to working with homogenous populations - by which I mean - when any of the rote descriptors were the same. The problem was partly surgery, where I barely knew the patients, anyway, didn’t meet them for much time prior to them being wheeled into the OR, and the surgeries would often repeat, within a day (if the patient comes in for surgery; ie, it’s not emergent, you might just meet them in anesthesia pre-op). And it’s the same procedure. Had I actually known them, had the time, the wherewithal to come in before 5 to have enough to do so and get the requisite work done - it would have been different.

Funny thing about the HIV** service, actually. I’m in the county hospital – where I want to be. Where I’ve wanted to be for so many years. We have translators on staff and on phones for a reason. But in 3 weeks, I haven’t used any of those resources. It’s not the demographic of the epidemic here – and that isn’t even true. Is it the demographic of those who are less likely to have been tested? Or, for some reason, not as many are as almost-dying? (Because more newly infected, maybe, relatively newer in the epidemiology?) I don’t know.

**I change how I answer the phone and introduce myself to patients, at times. “HIV consult room/ AIDS.” “with the HIV doctors.” And what do you say when the patient has a roommate? But doesn’t that apply to all conditions, really? No HIPAA in a hospital. Not within the rooms, among patients, their family and friends. 

 I’ve only done two weeks of inpatient medicine at the university hospital, for pediatrics. Kids, kids that sick, are eligible for Medicare. So they weren’t anyone in particular. There was the patient who lived on a reservation. The few in foster care/ adoptive situations suspicious of abuse or neglect. It’s the “better off” ones I don’t understand. Rather, I don’t understand why I’m there. Why there. I’m not needed. (and “I”, in this case, am anyone. Nothing in particular about me). It’s not what I want to be doing.

One thing about HIV is that Occam’s razor**** doesn’t apply. Ever. There is no need to connect a constellation of disparate symptoms – rather, you try, but it could very well, very likely, be multiple processes. Our service has been about three times busier than usual, apparently. I’ve seen almost every major opportunistic infection, at this point. With HIV, that’s the dangerous part, that’s what kills you – it’s not the virus itself. It’s the lack of immune system induced by the virus. Things that don’t make most people sick, do. Things that are rare, aren’t. You cease to be able to fight back – and everything, greedy everything – bacteria, viruses, fungus, parasites, and your own cells working against you (cancer) – takes advantage. Opportunistic. Opportunists. Who else preys on the down-and-out.

****House talks about this a lot. It’s more likely to be one process than many. Not here.

Why so sick. Why here. And why, with this disease, are they eligible for more services than people without this disease. In some ways. You can get aid to buy medication. You can get into clinics with multi-disciplinary services – the one here and another one I worked in have a psychiatrist on staff, social workers, case managers, people to help with housing, etc. There are pharmacies that are specialized in HIV medications (in this city, at any rate. But this was one of the initial epicenters), and you can ask them to make “blister packs” for patients. It’s a disease with many medications, but not always, not anymore. It was, what, 30 pills at one time. Now, you can get away with one per day. And depending on how good/bad your immune system is, a few more. Some patients are on seven, ten or so. And as the people, as the epidemic ages, they’ve got high cholesterol, maybe diabetes***, a lot have mental health issues as well, high blood pressure, etc etc etc…

***Though, in general, it’s one of the adult populations in the US with the lowest rate of obesity. The sickest ones, anyway.

But do pharmacies make blister packs for those patients? A Monday, Tuesday, etc; at least what I’m picturing. Is it available for anyone else? I’ve never heard of that. Not until now. I could be wrong.

Why this disease. Why now. I’ve seen babies die – almost never happens here, anymore. The rate I calculated for our health district in Cameroon was about 10%. One village was 25, 30%. But that’s one village, one place where truckers went through to Gabon. The country itself, though, is between 5 and 6% - lower than East, Southern Africa. When I was in Kenya, the rate in that health district was about 30%, over tens of thousands of people. Or more. For one island, it’s 90%, actually. One good thing – there’s no stigma at that point. Little. We had an obvious tent (and a few interior rooms) at a large hospital in town, everyone knew it was AIDS, but so many, so many people were there….

I don’t know what to say here. Or what not to say. What is the stigma, here. I’m sheltered, I’m in the health care system at a technically liberal, open-minded school in a technically liberal, open-minded city. A city with one of the highest prevalences of HIV in the US. I don’t know.

One patient, who’s been in the hospital a few weeks now, not getting better (I hope. I hope he is this weekend, did this weekend. Otherwise, he says he’s leaving on Monday), has started refusing daily labs because he’s so tired of getting stuck with needles. Bleeding, being bled. He’s a difficult stick, it seems, and in him, not because of IV drug use. (That’s the case for many patients I’ve seen. They “have no veins,” even for small blood draws, you have to put a central line in one of the largest neck veins. A jugular line, maybe. To have any access at all. The arm veins are all too scarred. When that isn’t the case, though, they’re less likely to create an easier port of access). But I’m a “difficult stick,” too. I could commiserate on the multiple times his skin was pierced to get one vial in the morning. (Up to seven, once, for me). I’ve since learned exactly which vein is easiest, and I show the phlebotomist every time. He does that too, but they’ve already used those many times. One morning, he told me how they missed, or didn’t get the tube connected (or disconnected) in time, and his blood spurted. I had a moment of terror. The interior recoil of “…it wasn’t me.” His blood, in my face, and as I pictured it, in my eye. It happened with a patient of mine, once, but she wasn’t HIV positive. (Actually, we didn’t test her. The potential exposure was essentially nil. It wasn’t worth it to go on post-exposure prophylaxis, not for that). What he described was maybe more, though. Knowing what’s in his blood. A lot of virus, maybe, probably, still. Rafael Campo has a story about that – it happened in the same hospital where I am now. Exactly one floor above, I imagine. Where the initial AIDS ward was. Exactly one floor above where this patient is now. It was the early nineties then, though. So much less known, so much less treatment at all. A poet exposed, my mentor exposed. I wasn’t, not this time. We-are-our-patients-are-us. What’s more human than that? A disease, an infection anyway, can jump. Person-to-person. It happens with non-human primates, too (current theories on how HIV mutated to be able to infect human hosts, from simian immunodeficiency virus (SIV). Another story). Monkey diseases can make us sick. Goat diseases. Pig diseases. Bird diseases. (Easy argument for evolution).

One of the intimacies of medicine. It’s amazing to listen to hearts, lungs again. To see, hear, feel, think, and learn. From all of that. But with this—the thing making my patient sick, the thing that’s been inside of so many of his cells, that’s been there (in his case) since at least the early eighties, when he was first diagnosed, that’s been making uncountable copies of itself, using him. Intercalating into his DNA, into the substrate that made him, him. And that thing, exactly, going into other people. Host to host. That little not-even-alive strand of molecules that starts to define him, in hospital (and elsewhere) parlance. “HIV patient,” “patient with HIV,” in the HIV/AIDS clinic, 58 year old man with HIV (and then we cite the current numbers of his infection. Disease). How many other, unchosen, permanent connections.

~j